Use of the femoral vein ('groin injecting') by a sample of needle exchange clients in Bristol, UK

BACKGROUND: Use of the femoral vein for intravenous access by injecting drug users (IDUs) (commonly called 'groin injecting') is a practice that is often observed but on which little is written in the literature. The purpose of this study was to describe self-reported data from a sample of groin injectors on the natural history and rationale regarding their groin injecting, to inform future research and the development of appropriate harm reduction strategies. METHODS: A convenience sample of groin injectors willing to participate in a semi-structured interview were recruited through the Bristol Drugs Project Harm Reduction Service. The interviews were conducted over the period of one week. Data on transition to groin injecting, rationale for use and incidence of problems were collected. RESULTS: Forty seven IDUs currently injecting in their femoral vein ('groin') were interviewed, 66% (n = 31) male and 34% (n = 16) female. Their mean age was 31 yrs (range 17 to 50 yrs; SD = 7.7). The mean length of time since first injecting episode was 9.6 yrs (range 6 mths to 30 yrs; SD = 7.0). The mean length of time since use of the groin began was 2.6 years (range 1 mth to 15 yrs; SD = 3.3). The mean length of time between first injection and first use of the groin was 7.0 yrs (SD = 7.0). One person had used no other area for venous access prior to using the groin, nine people had used one, nine people had used two, 10 people had used three, five people had used four and 13 people had used more than four areas. The main reason given for starting to inject in the groin was that 'no other sites were left'. However further discussion identified this meant no other convenient sites were accessible. Practises such as the rotation of injecting sites, as advocated in many harm reduction leaflets, were reported to be difficult and unreliable. The risk of missing the vein and subsequently losing the 'hit' was considered high. Use of the non-dominant hand to administer injections was problematic and deterred rotation between arms. The groin site was reported to be convenient, provide quick access, with little mess and less pain than smaller more awkward veins. The formation of sinuses over time facilitated continued use of the groin. Approximately two thirds of participants had experienced difficulty gaining IV access at their groin. Common problem included scar tissue occlusion, swelling and pain. Some reported infections and past history of deep vein thrombosis. CONCLUSION: Use of the groin was perceived to be convenient by the study group. Problems following safer injecting advice were identified, including dexterity difficulties leading to fear of losing the 'hit'. Health problems at the groin site did not deter use. These results suggest further qualitative work is needed to explore the difficulties in following safer injecting advice in more detail and inform the development of more appropriate advice. Further quantitative work is necessary to establish the prevalence of groin injecting amongst IDUs and the incidence of associated problems. There is a need for a longitudinal study to examine the relationship between injecting technique and loss of patency of veins. If protective factors could be identified, evidence-based safer injecting advice could be established to preserve peripheral veins and reduce use of the groin site, which is high risk and associated with serious adverse consequences

How do the narratives of depressed adolescents and their parents compare ?

This qualitative study used psychoanalytically informed narrative analysis to explore the narratives of two clinically-depressed adolescents alongside their parents’ narratives. The study also aimed to explore the co-construction of narrative as observed in psychoanalytic psychotherapy sessions. Two cases were transcribed and analysed. For each case, two adolescent therapy sessions were compared with one parent session. From this analysis, several overlapping themes were seen to arise between the adolescent’s and their parent’s narratives. These themes included a sense of persecution and anxiety related to expressing distressing emotion. It is suggested that the way in which the adolescents’ narratives often mirrored their parents’ narratives indicates a close link between how the adolescents and their parents understood and experienced the world around them. Significantly, it is argued that the difficulties faced by the parents – as seen principally in their narratives revealing a sense of persecution and difficulty expressing distressing emotion – combine to leave the adolescent feeling isolated, fearful and lacking capacity to manage the tumultuous period of adolescence. These factors are considered to be key to the adolescent’s difficulties and, as such, contributing to their depression. Several comparable themes were also seen to arise between the two depressed adolescents . These themes included an idea that talking about emotions might be dangerous, the difficulty of being in between quarrelling family members, lack of belief-in-self and a wish for robust containment. It is hoped that this small study supports the ongoing need for parent work within resource-pressurised times and adds to an understanding of contributary factors in adolescent depression

How do the narratives of depressed adolescents and their parents compare?

This qualitative study used psychoanalytically informed narrative analysis to explore the narratives of two clinically-depressed adolescents alongside their parents’ narratives. The study also aimed to explore the co-construction of narrative as observed in psychoanalytic psychotherapy sessions. Two cases were transcribed and analysed. For each case, two adolescent therapy sessions were compared with one parent session. From this analysis, several overlapping themes were seen to arise between the adolescent’s and their parent’s narratives. These themes included a sense of persecution and anxiety related to expressing distressing emotion. It is suggested that the way in which the adolescents’ narratives often mirrored their parents’ narratives indicates a close link between how the adolescents and their parents understood and experienced the world around them. Significantly, it is argued that the difficulties faced by the parents – as seen principally in their narratives revealing a sense of persecution and difficulty expressing distressing emotion – combine to leave the adolescent feeling isolated, fearful and lacking capacity to manage the tumultuous period of adolescence. These factors are considered to be key to the adolescent’s difficulties and, as such, contributing to their depression. Several comparable themes were also seen to arise between the two depressed adolescents . These themes included an idea that talking about emotions might be dangerous, the difficulty of being in between quarrelling family members, lack of belief-in-self and a wish for robust containment. It is hoped that this small study supports the ongoing need for parent work within resource-pressurised times and adds to an understanding of contributary factors in adolescent depression

Going into the groin: Injection into the femoral vein among people who inject drugs in three urban areas of England

Background: There have been increasing concerns about injection into the femoral vein – groin injecting – among people who inject drugs in a number of countries, though most studies have been small. The extent, reasons and harms associated with groin injecting are examined. Method: Participants were recruited using respondent driven sampling (2006–2009). Weighted data was examined using bivariate analyses and logistic regression. Results: The mean age was 32 years; 25% were women (N = 855). During the preceding 28 days, 94% had injected heroin and 13% shared needles/syringes. Overall, 53% reported ever groin injecting, with 9.8% first doing so at the same age as starting to inject. Common reasons given for groin injecting included: “Can’t get a vein elsewhere” (68%); “It is discreet” (18%); and “It is quicker” (14%). During the preceding 28 days, 41% had groin injected, for 77% this was the only body area used (for these “It is discreet” was more frequently given as a reason). In the multivariable analysis, groin injection was associated with: swabbing injection sites; saving filters for reuse; and receiving opiate substitution therapy. It was less common among those injecting into two body areas, and when other people (rather than services) were the main source of needles. Groin injection was more common among those with hepatitis C and reporting ever having deep vein thrombosis or septicaemia. Conclusions: Groin injection was common, often due to poor vascular access, but for some it was out of choice. Interventions are required to reduce injecting risk and this practice

Not in the vein: 'missed hits', subcutaneous and intramuscular injections and associated harms among people who inject psychoactive drugs in Bristol, United Kingdom

Background: The extent of intentional or accidental subcutaneous and intramuscular injections and the factors associated with these have rarely been studied among people who inject drugs, yet these may play an important role in the acquisition bacterial infections. This study describes the extent of these, and in particular the factors and harms associated with accidental subcutaneous and intramuscular injections (i.e. ‘missed hits’). Methods: People who inject drugs were recruited using respondent driven sampling. Weighted data was examined using bivariate analyses and logistic regression. Results: The participants mean age was 33 years (31% aged under 30-years), 28% were women, and the mean time since first injection was 12 years (N = 329). During the preceding three months, 97% had injected heroin, 71% crack-cocaine, and 16% amphetamines; 36% injected daily. Overall, 99% (325) reported that they aimed to inject intravenously; only three aimed to inject subcutaneously and one intramuscularly. Of those that aimed to inject intravenously, 56% (181) reported ever missing a vein (for 51 this occurred more than four times month on average). Factors associated with ‘missed hits’ suggested that these were the consequence of poor vascular access, injection technique and/or hygiene. ‘Missed hits’ were twice as common among those reporting sores/open wounds, abscesses, or redness, swelling and tenderness at injection sites. Conclusion: Intentional subcutaneous and intramuscular injections are rare in this sample. ‘Missed hits’ are common and appear to be associated with poor injection practice. Interventions are required to reduce risk through improving injecting practice and hygiene

Shift

Second part of incidental music for the ballet Push (choreography: Russell Maliphant). Foxes Fox (69.28) and 'Freedom of the City’ (A 79.44, B 78.39) comprise two selected recordings with improvising musicians. These recordings are part of Beresford's regular collaboration with the London Improvisers Orchestra (especially in the annual Freedom of the City series), and Evan Parker, Louis Moholo and John Edwards (especially on the Foxes Fox CD). The two recordings highlight the ongoing processes of collaboration with improvising musicians which has been at the forefront of Beresford's work. In these recordings, and in the regular live performances in a wide variety of venues, Beresford explores the paradoxical principles of improvisation. Every performance is highly differentiated from every other, and yet all have the potential to sound the same. Every collaboration involves listening intently to his collaborators playing and responding to their music with his own, but where this listening may result in strategies of non-listening. The unpredictability of free improvisation rests on the structuring process of this unpredictability in order to create rich, satisfying music. This work is one in a constant state of refinement: each recorded artefact moves the research forward. Through the improvisatory process Beresford is trying to establish a flexible model for musical communication and meaning, whereby the artefact at the end of the process, while rewarding in its own right, is only an instantaneous window onto the process itself. Beresford’s work as improviser, composer and performer was profiled in The Wire (April 2002, May 2005). Publication dates include October 27, 2004 (Foxes Fox: Naan Tso) and May 1, 2005 (London Improvisers’ Orchestra: Freedom of the City 2005)